A WORLD BANK STUDY Public Disclosure Authorized Public Disclosure Authorized The Path to Universal Health Coverage in Public Disclosure Authorized Bangladesh BRIDGING THE GAP OF HUMAN RESOURCES FOR HEALTH Sameh El-Saharty, Susan Powers Sparkes, Public Disclosure Authorized Helene Barroy, Karar Zunaid Ahsan, and Syed Masud Ahmed The Path to Universal Health Coverage in Bangladesh A WORLD BANK STUDY The Path to Universal Health Coverage in Bangladesh Bridging the Gap of Human Resources for Health Sameh El-Saharty, Susan Powers Sparkes, Helene Barroy, Karar Zunaid Ahsan, and Syed Masud Ahmed © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 18 17 16 15 World Bank Studies are published to communicate the results of the Bank’s work to the development com- munity with the least possible delay. 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ISBN (paper): 978-1-4648-0536-3 ISBN (electronic): 978-1-4648-0537-0 DOI: 10.1596/978-1-4648-0536-3 Cover art: Sameh El-Saharty Library of Congress Cataloging-in-Publication Data has been requested The Path to Universal Health Coverage in Bangladesh • http://dx.doi.org/10.1596/978-1-4648-0536-3 Contents Preface xi Acknowledgments xiii Executive Summary xv Acronyms xxiii Chapter 1 Introduction 1 Overview 1 Two Key Dates: 2021 and 2032 1 Key Challenges 2 Chapter 2 The Path to UHC 5 The Health Care Financing Strategy 5 Chapter 3 HRH 11 Introduction 11 HRH Stock 11 HRH Production 14 Public Sector Salaries 15 Vacancy Rates and Recruitment 15 HRH Distribution—Facts and Factors 17 HRH Quality and Productivity 24 Work Environment 25 Notes 26 Chapter 4 HRH Policy-Making Process 27 Introduction 27 Major HRH Challenges 27 A Complex and Sometimes Contradictory Array of National Policies 28 A Highly Centralized and Cumbersome Bureaucratic System with Weak Response Capacity 32 The Path to Universal Health Coverage in Bangladesh • http://dx.doi.org/10.1596/978-1-4648-0536-3 v vi Contents A Range of Powerful Stakeholders, Some with Competing Interests 34 Weak Regulatory and Enforcement Capacity 36 Conclusions 37 Notes 37 Chapter 5 HRH Policy Options for UHC 39 Introduction 39 Address HRH Shortages 39 Improve the Skill-Mix 43 Address Geographic Imbalances 48 Retain Health Workers 50 Adopt Strategic Payment and Purchaser Mechanisms 52 Establish a Central Human Resources Information System 52 Target HRH Interventions to Improve Maternal and Newborn Health 52 Appendix A Health Coverage and Service Delivery System 53 Public Service Delivery System 53 Staffing of Primary Health Care Centers 55 Human Resources for Health Production 56 Alternative Medical Care Providers 60 Appendix B Summary Implementation of HRH Policies 63 Appendix C Economic Analysis for Options to Increase Health Care Providers by 2021 65 Objectives 65 Methods 65 Analysis and Findings 71 Discussion 77 Notes 85 References 87 Boxes 1.1 Good in Parts 3 3.1 The Brain Drain and Other Lost Assets 13 3.2 Training Innovations 15 3.3 Push and Pull Factors—All toward Urban Areas 19 The Path to Universal Health Coverage in Bangladesh • http://dx.doi.org/10.1596/978-1-4648-0536-3 Contents vii 3.4 Informal Sector/Semiqualified and Allopathic Providers 21 3.5 Community Health Workers 22 5.1 Kenya: An Emergency Hiring Plan to Rapidly Scale Up the Health Workforce 41 5.2 Afghanistan: Community Midwifery Education Program 46 5.3 Nepal: Trained Outreach Workers Linking the Community to the Health System 47 5.4 Thailand: Integrated Interventions Enhance Equitable Distribution of Physicians Nationally 49 5.5 Chile: Well-Designed Incentive Package Successfully Addressed Physician Retention 51 Figures 2.1 Sequencing of the UHC Plan 6 2.2 Proposed Evolution of Health Financing 7 2.3 THE Per Capita 8 3.1 Density of HCPs per 10,000 Population 12 3.2 Health Workforce Registered with the Bangladesh Medical and Dental Council (BMDC) and Bangladesh Nursing Council (BNC), 1997, 2007, and 2013 13 3.3 Filled-In Posts as Percentage of Sanctioned Posts by Year 16 3.4 Process and Responsibilities for Creation of a New Post 17 3.5 Rural–Urban Distribution of HCPs by Type 18 3.6 Distribution of HCPs by Divisions (per 10,000 population) 20 4.1 Process to Fill a Vacant Position 33 5.1 Scenario II: Recruitment of Additional HCPs to Reach a Physician: Nurse: CHW Ratio of 1:1.5:1 by 2021 40 5.2 Physician-to-Nurse Ratio and Health Service Utilization by Division 45 5.3 Physician-to-Nurse Ratio and Health Outcomes by Division 46 A.1 Public Service Delivery System 54 C.1 Budget for Salary and Allowance for All Health Workers 67 C.2 Projection of the Number of Filled Positions (Laissez-Faire Scenario) 69 C.3a Projected Numbers of Physicians and Nurses (Laissez-Faire Scenario) 71 C.3b Projected Budget for Physicians and Nurses (Laissez-Faire Scenario) 71 C.4a Projected Numbers of Physicians and Nurses (HRM Policy) 73 C.4b Projected Budget for Physicians and Nurses (HRM Policy) 73 C.5a Scenario I: Projections to Reach a Physician: Nurse: CHW Ratio of 1:1:1 in 2021 76 The Path to Universal Health Coverage in Bangladesh • http://dx.doi.org/10.1596/978-1-4648-0536-3 viii Contents C.5b Scenario I: Budget Projections to Reach a Physician: Nurse: CHW Ratio of 1:1:1 in 2021 76 C.6a Scenario II: Projections to Reach a Physician: Nurse: CHW Ratio of 1:1.5:1 in 2021 79 C.6b Scenario II: Budget Projections to Reach a Physician: Nurse: CHW Ratio of 1:1.5:1 in 2021 79 C.7a Scenario III: Projections to Reach a Physician: Nurse: CHW Ratio of 1:2:1 in 2021 80 C.7b Scenario III: Budget Projections to Reach a Physician: Nurse: CHW Ratio of 1:2:1 in 2021 80 CA.1 Methodology Used to Determine Scenarios I, II, and III 84 CA.2 Steps in Developing Different Human Resources for Health Policy Options 85 Tables 2.1 Public Expenditure Required for UHC 8 3.1 Annual Production Capacity of Health Workforce Including Private Sector, 2011 14 3.2 Basic Pay Scale for Different Cadres of Health Professionals under Public Sector 16 4.1 HRH-Related Plans and Programs 29 5.1 Three Scenarios for Additional HCPs until 2021 40 5.2 Deployment of New Recruits by Region 50 A.1 Staff Mix at Upazila Level and Below in the Formal Sector 55 A.2 Informal HCPs at PHC Level 57 A.3 Categories of Health Workforce with Training Institutes, Admission Criteria, and Duration 58 A.4 Number of Places for Postgraduate Courses Offered by Different Institutions 60 A.5 Number of Fellowship and Membership Awardees